الفهرس 
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Abstract
Subcutaneous injection of anticoagulants is a common nursing intervention extensively used to prevent or treat thromboembolism. Among anticoagulants administered via SC injection, injection of low molecular weight heparins, such as enoxaparin resulted in local problems as pain, bruising and hematoma at the injection site. These local problems can cause anxiety, rejection of the treatment by patients, and decrease patient’s confidence in nurse’s efficiency. One of the applications preventing the formation of these problems is cold application (Dadaeen et al., 2015).
Cold application is a non-pharmacological, inexpensive treatment for many things such as pain, swelling, hematoma, bruising, traumatic injury, and athletics trauma. With cold application, the vessels will be contracted, the blood flow decreased, the inflammatory process reduced, and metabolism of the tissue decreased. All these effects influence the intensity of the pain, and the size of bruising and hematoma (Alabdalhai et al., 2017).
Aim of the study:
This study aimed to investigate the effect of cold application on local problems among patients receiving subcutaneous enoxaparin.
Research hypothesis:
• The pre-injection cold application at the injection site will have a positive effect in prevention and reduction of pain intensity among patients receiving subcutaneous Enoxaparin.
• The pre-injection cold application at the injection site will have a positive effect in prevention and reduction of bruising among patients receiving subcutaneous Enoxaparin.
• The pre-injection cold application at the injection site will have a positive effect in prevention and reduction of hematoma among patients receiving subcutaneous Enoxaparin.
Research design:
Self-controlled trial design used to conduct this study.
Setting:
This study conducted in the following: general surgery department, orthopedic surgery department, and chest intensive care units at Beni-Seuf university hospital.
Subjects:
• Purposive sample of 60 patients from the previously mentioned departments included in the study.
• Inclusion criteria: Only newly admitted conscious patients who receive subcutaneous injections of 40 mg of low molecular weight heparin (Clexane) twice a day for prophylaxis or treatment and able to rate the pain scale intensity.
• Exclusion criteria: pregnancy, intake of any other anticoagulant drugs and patients with abnormal liver functions, with coagulation or hematological diseases and patients with cognitive impairments.
Tools used to accomplish the aim of this study:
Four tools were used in the current study as follows:
1. Patient assessment tool: This tool was developed and filled by the investigator to suite the study aim. It included two parts: Demographic Data to assess demographic characteristics of studied patients as age and gender and Medical Data: It used to collect data regarding patient’s diagnosis, medical history, height, weight, body mass index, laboratory investigation and patient care setting.
2. Bruising Category Scale: This scale was used by the investigator for measurement of bruising which was adopted from relevant literature. The investigator measured bruising after 48 and 72 hours from injection administration.
3. Visual Analogue Scale for pain (VAS): This scale was used by the investigator to assess pain intensity which was adopted from relevant literature. Pain was measured immediately following each injection; the patients were asked to report their current level of perceived pain at the time of injection.
4. Hematoma Formation Scale tool: This scale was used by the investigator for measurement of hematoma which was adopted from relevant literature. The investigator measured hematoma after 48 and 72 hours from injection administration.
Results:
The results of the study showed that:
More than half (58.3%) of the studied patients their age <50years with a mean age of 45.43±18.18, the male group was more than two third (68.3%) and more than half (68.53%) of them were from orthopaedic unit and their current medical diagnosis were fractures. As well the studied patient’s BMI mean score was 28.14± 6.44, while mean score of INR was 1.11± 0.11.
All studied patients (100%) had pain during technique A (without cold application) used, while more than three quarter (81.6%) of them had pain during technique B (with cold application).
More than half (53.3%) of studied patients developed bruise at injection site during technique A used, while, less than one quarter (21.7%) of them had bruise during technique B used.
The majority (95%) of the studied patient did not develop hematoma whether cold applied at injection site or not.
Pain intensity level reported by patients when technique B used was statistically highly significantly lower than technique A at P < 0.001.
The difference between the two techniques in extent of bruise after 48 & 72 hours was statistically highly significant at p-value 0.000671 and 0.001522 respectively and the proportion of cases with no bruise in Technique B was higher than for technique A.
There were no difference in hematoma categories between 48h and 72h also there was no statistically significant difference can be detected between the two techniques regarding the hematoma scale levels at p value > 0.05.
There was statistically significant relation between the patients’ pain intensity and their demographic characteristics; gender (p <0.05).
There was statistically significant relation between the patients’ extent of bruise and their demographic characteristics; age (p <0.05).
There was insignificant relation between the patients’ pain intensity, the extent of bruising, hematoma and their medical data.
Conclusion:
Based on findings of the current study, it can be concluded that: When studied patients received enoxaparin without cold application, all of them had pain and more than half developed bruise at injection site but when they received injection with cold application only three quarter of them had pain and less than one quarter developed bruise. Meanwhile, the majority of the studied patient did not develop hematoma whether cold applied at injection site or not. Thus it could be said that the pre-injection cold application at the injection site was effective in reducing or preventing the occurrence of pain and bruising. Moreover, there was statistically significant relation between the patients’ pain intensity, bruising and their demographic characteristics.
Recommendations:
Based on the results of the present study, the following recommendations are suggested:
It is recommended that the cold application should be included in the subcutaneous injection protocol of enoxaparin.
Providing on-going and regular in-service educational programs on standard protocol for the administration of subcutaneous LMWH to nurses to enhance evidence based practice.
Hospital protocols regarding SC injection administration especially enoxaparin should be developed and reviewed regularly as updates and new evidence for best practice are constantly emerging and nurses should be educated on updated protocols.